Ganglion cysts of the cruciate ligaments

Atraumatic intra-articular, extra-synovial ganglion cyst of the lateral knee deep to the iliotibial band: A case report and review of the literature

Key Clinical Message

We highlight the rare case of an atraumatic, intra-articular ganglion cyst of the lateral knee deep to the iliotibial band that was successfully treated nonoperatively, a pathology yet to be reported in orthopedic literature.

Abstract

Ganglion cysts are mucin-filled synovial cysts commonly found on the dorsal surface of the hands and feet. Intra-articular ganglion cysts of the knee are rare, and when they present clinically, are typically treated operatively through arthroscopic surgery. We present the first reported case of an atraumatic intraarticular, extra-synovial ganglion cyst of the lateral knee located deep to the iliotibial band that was successfully treated without operative intervention through repeated intra-articular aspirations of the knee.

Intercondylar Notch Pathology

The intercondylar notch of the knee is a relatively small area. However, numerous rare pathologies can arise in this region. A majority of the existing literature has focused on the cruciate ligament injuries, yet there are several other entities that can cause knee pain from within the intercondylar notch. This review focuses on identifying the various diagnostic and treatment options for rare benign and malignant lesions including ganglion cyst formation, mucoid degeneration, benign proliferative conditions, and intra-articular tumors. These entities are most often diagnosed with advanced imaging studies and treated arthroscopically. While rare, these pathologies are important to identify in patients with ongoing vague knee pain.

Posterolateral Bundle Resection for an Anterior Cruciate Ligament Ganglion Cyst

The incidence of intra-articular ganglion cysts of the anterior cruciate ligament (ACL) is low and symptomatic presentation of this pathology is even lower. Nevertheless, symptomatic cases pose a real challenge for the orthopaedic community, as no general consensus exists regarding the most appropriate treatment. The purpose of this Technical Note is to describe the surgical treatment of an ACL ganglion cyst by arthroscopic resection of the entire posterolateral bundle of the ACL in a figure-of-four position after conservative treatment has failed.

Intra-Articular Ganglion Cysts of the Knee

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Magnetic resonance imaging (MRI) without contrast is sufficient to diagnose an intra-articular ganglion cyst of the knee. MRI with intravenous contrast may be considered for cysts in the infrapatellar fat pad, which are not a typical presentation.

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The current literature supports treating symptomatic cases or those discovered accidently during knee arthroscopy with arthroscopic excision.

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Although aspiration of these cysts results in a higher recurrence rate than excision, it is associated with quicker recovery. Thus, aspiration might be chosen as an initial treatment for anyone who would like to avoid surgery or requires a rapid recovery, including professional athletes.

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Open excision may be considered for infrapatellar fat pad cysts that are >4.5 cm in size.

Anterior cruciate ligament ganglion causing flexion restriction: a case report and review of literature

Ganglion cysts originating from the anterior cruciate ligament (ACL) are uncommon. Often asymptomatic, they infrequently present with non-specific symptoms such as knee pain, stiffness, clicks, locking or restriction of knee extension. However, the patient we report presented with knee flexion restriction. A 37-year-old Chinese gentleman, with no history of knee trauma, presented with left knee pain. Left knee range of motion (ROM) was from 0 to 110 degrees. Magnetic resonance imaging (MRI) scan revealed a 1.5 cm × 3.3 cm × 1.7 cm cyst located in the intercondylar region arising from the ACL and extending predominantly posteriorly. Arthroscopy confirmed an intrasubstance ACL ganglion cyst, which was extending posteriorly. Complete excision of the cyst was performed. At 1-year follow-up, the patient regained knee flexion of 130 degrees. We describe one of the largest ACL ganglion cysts. Such cysts often extend anteriorly and impinge onto the roof of the intercondylar notch during knee extension, thus restricting extension. The restriction in knee motion in our patient was in flexion instead; this was because the cyst took an unusual course of extension predominantly in the posterior direction. Although rare, it must be included as a possible differential diagnosis when patients present with such knee symptoms.

Cysts of the anterior horn lateral meniscus and the ACL: is there a relationship?

OBJECTIVE

Parameniscal cysts have a very high association with meniscal tears in all locations except the anterior horn lateral meniscus (AHLM). The common insertion of the anterior cruciate ligament (ACL) and the AHLM root may provide a pathway for disease. The purpose of our study was to determine if cysts of the ACL are the origin of cysts adjacent to the AHLM.

MATERIALS AND METHODS

Radiology reports of all magnetic resonance (MR) examinations of the knee over a 7-year period were searched for "cyst", "ganglion", and "ganglia". Two fellowship-trained musculoskeletal radiologists independently reviewed those MR examinations reported to have a possible cyst of the AHLM and/or the ACL. The study group consisted of those patients with a cyst located adjacent to the AHLM but no meniscal tear of the adjacent meniscus. The ACL in each of these patients was evaluated for the presence of a cyst. Comparison with age- and gender-matched controls was performed.

RESULTS

Of 708 cases that contained the word "cyst", "ganglion", or "ganglia", 121 reports indicated a possible cyst of the ACL or AHLM. Twelve individuals had a cyst located adjacent to the AHLM with no meniscal tear. Six (50%) of these individuals had a cyst of the ACL; no ACL cysts were identified in the control group (p = 0.014). Interreader agreement for AHLM parameniscal cysts and AHLM tears was substantial.

CONCLUSIONS

Our results suggest that cysts adjacent to the AHLM may in part be explained by cysts or ganglia of the ACL.

Dual ACL Ganglion Cysts: Significance of Detailed Arthroscopy

Intra-articular ganglion cysts of the knee joint are rare and most frequently are an incidental finding on MRI and arthroscopy. Most of the previous studies have reported a single ganglion cyst in the knee. There have been previous reports of more than one cyst in the same knee but not in the same structure within the knee. We are reporting a case of dual ACL (anterior cruciate ligament) ganglion cysts one of which was missed on radiological examination but later detected during arthroscopy. To the best of our knowledge, no such case has been reported in the indexed English literature till date.

Mucoid degeneration of the anterior cruciate ligament: a case report

We report a case of mucoid degeneration of the anterior cruciate ligament (ACL). Mucoid degeneration of the ACL is a very rare cause of knee pain. There have been only some reported cases of mucoid degeneration of the ACL in the English literature. We reviewed previous reports and summarized clinical features and symptoms, including those found in our case. Magnetic Resonance Imaging is the most useful tool for differentiating mucoid degeneration of the ACL from an intraligamentous ganglion or other lesions in the knee joint. If this disease is considered preoperatively, it can be diagnosed easily based on characteristic findings.

Arthroscopic excision of ganglion cysts of the posterior cruciate ligaments using posterior trans-septal portal

PURPOSE

To evaluate clinical outcomes of arthroscopic excision of ganglion cysts involving the posterior cruciate ligament (PCL) using the posterior trans-septal portal in the knee.

METHODS

A retrospective study was performed of 15 cases of ganglion cyst involving the PCL treated at our institution over a period of 4 years. All the cysts were diagnosed and had their location confirmed preoperatively by magnetic resonance imaging (MRI). All the cysts were excised arthroscopically through the posterior trans-septal portal. All patients were followed up with MRI evaluation at a mean of 36 months after surgery. In addition, International Knee Documentation Committee (IKDC) scores and range of motion (ROM) were obtained preoperatively and postoperatively simultaneously with MRI to assess the surgical outcomes.

RESULTS

Most of the patients were male patients, and the mean age was 32 years. The most common presenting complaint was pain and difficulty in knee flexion. Preoperatively, the mean ROM was 3° to 110° and the mean IKDC score was 53 (range, 38 to 67; SD, 7.9). The location of the main cystic component was posterior to the PCL in 14 patients (93%) and anterior to the PCL in 1 patient (7%). After surgery, MRI evaluation at a mean follow-up time of 36 months showed no cyst recurrence. Postoperatively, the mean IKDC score was 91 (range, 70 to 99; SD, 9.3) and the mean ROM was 3° to 128°.

CONCLUSIONS

Ganglion cysts associated with the PCL can cause knee pain and limitation of knee flexion. MRI evaluation is a noninvasive method of diagnosing PCL ganglion cysts. Arthroscopic excision through the posterior trans-septal portal is a good option for relieving pain and preventing cyst recurrence.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Large infrapatellar ganglionic cyst of the knee fat pad: a case report and review of the literature

Introduction

Large ganglionic cystic formations arising from the infrapatellar fat pad are quite uncommon and only a few are mentioned in the literature. An open excision in these cases is mandatory.

Case presentation

We report the case of a large infrapatellar fat pad ganglion in a 37-year-old Greek man with chronic knee discomfort. The ganglionic cyst originated from the infrapatellar fat pad and had no intrasynovial extension. The final diagnosis was determined with magnetic resonance imaging of the knee, and the lesion was treated with surgery.

Conclusions

These lesions are asymptomatic in most cases but often are misdiagnosed as meniscal or ligamentous lesions of the knee joint. Nowadays, the therapeutic trend for such lesions is arthroscopic excision, but when there is a large ganglion, as in this case report, the treatment should be an open and thorough resection. This report is intended mostly but not exclusively for clinical physicians and radiologists.

Anterior cruciate ligament mucoid degeneration: a review of the literature and management guidelines

PURPOSE

Anterior cruciate ligament (ACL) mucoid degeneration is a rare encounter in clinical practice, different, but often confused with ACL mucoid cysts. Its pathophysiology remains unclear. However, recent publications have suggested that it might be underdiagnosed or misdiagnosed, and that the adverse effects of treatment by ACL resection might be underestimated. The object of this work was to summarize this scattered knowledge to improve patient management.

METHODS

The authors carried out an exhaustive and comprehensive review of up-to-date literature. An extensive search of the MEDLINE database was carried out using MESH terms (ganglion cyst, anterior cruciate ligament) and generic search terms (mucoid degeneration, hypertrophy).

RESULTS

Anterior cruciate ligament mucoid degeneration is determined by interstitial glycosaminoglycan deposits amidst the collagen bundles causing ACL hypertrophy, knee pain, and limited range of motion. It is thought to arise from a primary synovial lesion and is associated with arthritic change or subsequent to acute or repeated trauma. Diagnosis is made on MRI scans and confirmed on histopathological samples. Current treatment involving ACL arthroscopic resection is efficient on pain and range of motion but is not a benign procedure and causes knee laxity.

CONCLUSIONS

Anterior cruciate ligament mucoid degeneration needs to be more broadly known and properly diagnosed so that progress can be made in its management. Further research will be necessary to confirm the current trends in the literature, which suggest being less aggressive with ACL arthroscopic resection when dealing with mucoid degeneration and making more use of conservative measures such as notchplasty.

LEVEL OF EVIDENCE

Systematic review, Level IV.

Large intra-articular anterior cruciate ligament ganglion cyst, presenting with inability to flex the knee

A 41-year-old female presented with a 3-month history of gradually worsening anterior knee pain, swelling and inability to flex the knee. Magnetic resonance imaging (MRI) revealed a large intra-articular cystic swelling anterior to the anterior cruciate ligament (ACL), extending into the Hoffa's infrapatellar fat pad. Following manipulation under anaesthesia and arthroscopic debridement of the cyst, the patient's symptoms were relieved with restoration of normal knee motion. ACL ganglion cysts are uncommon intra-articular pathological entities, which are usually asymptomatic and diagnosed incidentally by MRI. This is the first reported case of an ACL cyst being so large as to cause a mechanical block to knee flexion.

Arthroscopic excision of the ganglion in the posterior septum by posterior trans-septal portal: report of two cases

We report two cases of ganglion cysts in the posterior septum of the knee joint, one as parameniscal cyst from the posterior horn of the lateral meniscus extending to posterior septum, and the other as a cyst located in the posterior septum adjacent to the posterior cruciate ligament, which were both arthroscopically excised expediently by posterior trans-septal portal. The posterior compartment of the knee is not readily accessible by ordinary arthroscopic portals, and therefore has been considered as 'blind spot' conventionally. The posterior trans-septal portal is useful for assorted diagnostic or manipulative procedures in the posterior compartment of the knee.

Ganglion Cyst of the Anterior Cruciate Ligament

We present the case of a 55-year-old woman with a presumed ganglion cyst associated with the anterior cruciate ligament (ACL), demonstrated by MRI. The ACL is an uncommon location for ganglion cysts to occur.

Relationship between mucoid hypertrophy of the anterior cruciate ligament (ACL) and morphologic change of the intercondylar notch: MRI and arthroscopy correlation

OBJECTIVE

The purpose of this study was to evaluate the relationship between mucoid hypertrophy of the anterior cruciate ligament (ACL) and morphologic change of the intercondylar notch.

MATERIALS AND METHODS

We retrospectively reviewed the 105 patients with knee magnetic resonance imaging (MRI) with or without knee arthroscopy [group 1: patients with arthroscopic notchplasty (N = 47), group 2: knee arthroscopy demonstrating intact ACL (N = 33), and group 3: patients with normal knee MRI but no arthroscopy (N = 25)]. Groups 2 and 3 served as an arthroscopic and MR control group, respectively. Two musculoskeletal radiologists reviewed all MR examinations. The intercondylar notch width, notch index (width of intercondylar notch/width of femoral condyle), transverse notch angle (TNA), sagittal notch angle (SNA), and notch area were recorded on axial and sagittal MR images at the midpoint of Blumensaat's line which was identified on sagittal images. The diameter of the ACL was recorded on coronal MR images at the posterior end of Blumensaat's line.

RESULTS

The mean values of the intercondylar notch width, notch index, TNA, SNA, notch area, and ACL diameter for the three groups were 16.0 mm/0.2/50.3 degrees /36.5 degrees /249.0 mm(2)/7.7 mm (group 1); 19.3 mm/0.3/52.9 degrees /40.2 degrees /323.4 mm(2)/4.8 mm (group 2); and 20.3 mm/0.3/51.4 degrees /39.1 degrees /350.8 mm(2)/4.5 mm (group 3). The intercondylar notch width, notch index, SNA, and notch area were smaller, and ACL diameter was thicker in group 1 compared with the other groups (p < 0.05).

CONCLUSION

Patients with mucoid ACL hypertrophy show a narrower notch, a steeper notch angle, and a smaller notch area than control groups.

Ganglion cysts of the posterior cruciate ligament

Ganglion cysts of the posterior cruciate ligament (PCL) are uncommon lesions found incidentally on MRI and arthroscopy. Twenty patients (11 males and nine females) with the mean age of 35 years presenting with a variety of knee signs and symptoms were found to have PCL cysts on MRI. Out of these, thirteen patients (65%) had isolated symptomatic PCL cysts and seven patients had associated chondral and meniscal lesions. Eight out of the 20 patients (40%) gave a history of antecedent trauma. On arthroscopy, the majority of the cysts were situated at the midsubstance of the ligament with inter-cruciate distension and no involvement of the substance of the ligament. The content of the cysts varied with the majority having yellowish viscous fluid and three containing serous and bloody fluid. All cysts were successfully treated arthroscopically through standard anterior, posteromedial and posterolateral portals with no signs of recurrence on MRI at a mean followup of 24 months. PCL cysts may clinically mimic meniscal or chondral lesions and preoperatively, MRI is essential for the diagnosis of ganglion cysts arising from the PCL. Ganglion cysts of the PCL can be successfully treated arthroscopically using standard portals.

Intra-articular ganglia of the knee joint associated with the anterior cruciate ligament: a report of 4 cases in 3 patients

Intra-articular ganglia are rare and mostly incidental findings on magnetic resonance imaging (MRI) and arthroscopy. We present 4 cases of intra-articular ganglion cysts associated with the anterior cruciate ligament (ACL) in 3 patients. The most commonly occurring symptoms were pain aggravated after stressing activities and limited knee range of motion. In 1 patient, ganglion cysts appeared in both knees with a time difference of 1 year. An MRI revealed typical signs of ganglion cysts in the substance of the ACL. Arthroscopy was performed for further evaluation and treatment. Histologic examination of the tissue removed revealed the presence of features consistent with ganglion cysts. Therefore, in the case of chronic knee discomfort with nonspecific clinical signs and symptoms and without a clear cause, an intra-articular ganglion cyst should be considered as causing pathology. An MRI is the most sensitive and specific method for diagnosis. However, the relatively slow progression of symptoms may delay the patient's decision to seek medical attention. Delayed diagnosis makes arthroscopic total resection of the ganglion technically demanding or not possible at all, and extensive debridement of the ACL may be required.

Snapping knee symptoms caused by an intra-articular ganglion cyst

Snapping knee syndrome describes the sudden movement of a soft-tissue structure across a bony prominence around the knee with a popping sound at some specific activity. Symptomatic snapping knee syndrome may result from an intra-articular tumor, but this situation is rare. To the best of our knowledge, an intra-articular ganglion cyst leading to snapping knee has not been reported previously. A 20 year old female with painful snapping knee was successfully treated by open en-bloc excision of the ganglion cyst sized 4.5 x 1.5 x 1 cm on the ligamentum mucosum. Snapping and pain were completely relieved after surgery. Although the snapping knee is not common over the antero-lateral portion of the knee joint, a ganglion cyst from the ligamentum mucosum is a possible cause.

Case report: intra-tendinous ganglion of the anterior cruciate ligament in a young footballer

A 20-year-old male medical student and keen rugby player presented with a 12-month history of progressively worsening right knee pain and stiffness with no history of trauma. Clinical examination revealed effusion and posterior knee pain exacerbated by end range movement and an extension lag of 15 degrees. Physiotherapy to improve the range of motion proved unsuccessful. Magnetic resonance imaging showed that the ACL was grossly thickened and displaced by material reported as mucoid in nature. There were also areas of focally high signal in relation to its tibial attachment and intra osseous small cysts. Arthroscopic examination revealed a ganglion related to the tibial attachment of the ACL and gross thickening and discoloration of the ACL. Biopsies were taken showing foci of mucoid degeneration in the ACL. A large intra-ACL mass of brownish coloured tissue was excised arthroscopically. Already at 2 weeks follow up the patient had greatly improved range of movement and was pain free. However, upon returning to rugby, joint instability was noticed and a tear of the ACL was confirmed.

This rare clinical condition can be diagnosed with MRI and arthroscopic debridement effectively relieves symptoms. This case report illustrates that augmentation or reconstruction may end up being the definitive treatment for athletes. It may also offer some support to the argument that mucoid degeneration and ganglion cyst formation share a similar pathogenesis to intra-osseous cyst formation.

Ganglion cysts of the anterior cruciate ligament: a series of 15 cases

PURPOSE

To increase awareness of the presence of ganglion cysts of the anterior cruciate ligament and to consider this diagnosis in any knee that has lost range of motion (ROM) in the absence of osteoarthritis.

TYPE OF STUDY

Case series.

METHODS

We present a series of 15 cases recorded over a period of 5 years illustrating the clinical presentation and additional pathology seen at arthroscopy. International Knee Documentation Committee scores were calculated at the recent follow-up to establish outcome of the surgery.

RESULTS

The cysts occurred predominantly in men with the most common presenting complaint being decreased ROM and pain. Overall, results were excellent with no recurrence of symptoms at a mean 36-month follow-up, but outcome does appear to be associated with other pathology present. ROM was improved with arthroscopic excision of the cyst in all cases that were impaired.

CONCLUSIONS

Although rare, ganglion cysts related to the cruciate ligaments of the knee should be considered in the differential diagnosis of a painful knee especially when associated with a decreased ROM and no evidence of osteoarthritis on radiographs. Other pathology can often be present, which may affect the overall outcome, but arthroscopic debridement of the ganglion cyst should be considered the treatment of choice in order to reliably restore active ROM.

LEVEL OF EVIDENCE

Level IV, Case Series.

Intra-articular ganglia arising from the posterior joint capsule of the knee

Magnetic resonance imaging (MRI) is an effective method to evaluate cystic lesions of the knee. Intra-articular ganglia of the knee joint was considered to be rare before the advent of MRI. However, because an MRI is often used to diagnose knee pathology, the reported prevalence of intra-articular ganglia has increased. We describe two cases of an intra-articular ganglion arising from the posterior joint capsule. Both cysts appeared to be arising from the posterior cruciate ligament by both MRI as well as arthroscopy through a lateral infrapatellar portal. However, arthroscopy through a posteromedial portal revealed the cysts to originate from the posterior joint capsule. It suggests that some of the ganglion arising from the posterior cruciate ligament reported in the literature might actually be from the posterior joint capsule. To prevent recurrence of a ganglion cyst, when preoperative MRI shows the mass to be located posterior to the cruciate ligaments, we recommend that the relationship of the ganglion cyst to the posterior joint capsule be evaluated at arthroscopy through the posteromedial or posterolateral portal.